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STATE OFCALIFORNIASTATE WATER RESOURCES CONTROL BOARD .•• UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ' COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT O ONE ITEM ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED 917E ❑ 2 INTERIM PERMIT ❑ q AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) MINDICATE =1 NAME OF OPERATOR �� NEAREST CROSS STREET PARRCEL#(OPfONAUfSITE PHONEsWITH AREACODE CORPORATION O INDIVIDUAL =PARTNERSHIP Q LOCALAGENCY N owner of UST Is a PublicDISTRICTS' E-3 COUNTY-AGENCY' �STATE-AGENCY' O FEDERAL AGENCY' agency.mnplele the iWlawing:name W Supervisor of division.sectbn,m office which operates the UST TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR///��___ ❑ ✓ IF INDI 3 FARM AN sOF TANKSAT SITE E.P.q, I.p,#rppllprtyl ❑ ❑ q PROCESSOR 5 OTHER RESERVATION OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal DAYS: NAME(LAST,FIRST) PHONE S WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE If. PROPERTY OWNER INFORMATION- MU T BE COMPLETED NAME Ao / CARE OF ADDRESS INFORMATION MAKING OR STREET ADDRESS ✓ bonblydbale l^ /'J I I INDIVIDUAL = LOCAL AGENCY 1::1 STATE-AGENCY l 0 L (]CORPORATION 0 PARTNERSHIP 000UNTY-AGENCY =1 FEDERAL#GENCV CITY NAME STATE ZIP CODE P ONE s WITH AREA CODE III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NA OF OWNER CARE OF ADDRESS INFORMATION AILING OR STREET ADDRESS )1 ✓ bm binicab Z 9 / p4`— AIO�A� d = INDIVIDUAL 0 LOCALAGENCY 0 STATE CITY NAME / �[/ WY CORPORATIONPMTNERSHIP COUMVAGENCY 0 FEDERAL-AGENCY O�5A� I/L� STATE 21P CODE PHONE i WITH AREA CODE !/L/V 'V �(.( TATE ��SZ �a - 3E IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- -u V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ boa lit lydic le D I SELFINSURED L-1 2 GUARANTEE 0 3 INSURANCE O a SURETY BOND 5 LETfEROFCAED1T [-16 EXEMPTION 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ 11. 111.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY#(J07/S9 LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 9UPVISOR-DISTRICT CODE -OPTIONAL s. I I S FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE"MATON ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATK)NS FORM A(3N3) FORD03 V